Lmbar Case Study

DOI: 7/7/2015. The patient is a 48-year-old male cleaner who sustained a work-related injury to his back while moving a heavy bookcase. As per OMNI, the patient was diagnosed with lumbar degeneration, thoracic or lumbosacral neuritis and myofascial pain.

He was given a refill prescription for gabapentin 600 mg, 1 tablet orally, 3 times a day for 30 days, # 120 and hydrocodone/APAP tablet, 10/325 mg 1 tablet 4 times a day for 30 days #120. The patient continues on stable doses of medications in a responsible and compliant fashion.

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

DOI: 2/11/2014. This is a case of 37-year-old male production worker who sustained a work-related injury to his back when he bent over to scan the rack tracking bar. As per OMNI, he was initially diagnosed with lumbar spine sprain/strain and gastritis secondary to non-steroidal anti-inflammatory drugs. Patient is status post left-sided L4-5 discectomy on 03/11/2015.

Based on the medical report dated 01/20/16, the patient reports that his low back pain is rated as 9/10 into the right lower extremity. It’s experienced between 76% and all of the time he is awake. Some of the patient’s daily activities are being prevented by this symptom. He reports numbness and tingling in his right lower extremity.

Treatments rendered to date included medications, physical therapy, 3 sessions of acupuncture treatment, an e-stim unit, and lumbar back support.

DOI: 03/11/2009. Patient is a 60-year-old male truck driver who sustained a work-related injury to his back when he tried to catch a box from falling. He is status post two back surgeries on 07/06/2009 and has reached Maximum Medical Improvement as of 06/19/2012.

Based on the progress report dated 02/09/16, the patient presents for follow-up. He describes ongoing difficulty with pain in both shoulders, wrists, low back and the bilateral lower extremities from the knees to the calves. His symptoms include pain, spasms, numbness and tingling. He rates his pain level as a 9/10 in intensity, but it is reduced to a 7/10 with use of his medications. He reports that morphine is helping, but he is still taking 5-6 Norco a day. He is also taking a stool softener three times a day as well as Linzess. However, he continues to have significant constipation.

Based on the progress report dated 09/29/16, the patient continues to be tearful having difficulties with dealing with her limitations and problems with chronic pain in her neck and upper back. The subacromial injection in her right shoulder gave her a transient relief of her clinical symptoms in her right shoulder. Patient also states that ibuprofen prescription was filled. It was noted that her Ultracet prescription was written 37/325 mg and was not

DOI: 12/29/2015. Patient is a 38-year-old male customer engineer who sustained injury when he stepped out of the car and slipped. As per OMNI notes, the patient sustained strain to the lower back.

02/09/16 Progress Report noted that the patient’s current medication regimen provides moderate pain relief without any adverse effects. The patient stated that he has seen Dr. Smith for IT pump clearance and would like to proceed with the trial. He has chronic lumbar back pain. The pain radiates the left buttock, left posterior thigh, left lateral thigh, left lower leg, left foot, and right lateral thigh. The patient describes the pain as sharp, dull, aching, bumping, stinging, and throbbing. The onset was sudden immediately after the injury. The symptoms are constant and the episodes occur daily. The symptoms are described as severe and worsening. Back motion, lifting, and bending exacerbate the symptoms. Associated symptoms include leg numbness, foot numbness, leg weakness, and foot weakness. Current treatment includes opioid

Patient has been previously certified with 80 Tablets of MS Contin 30 mg and 165 Tablets of Norco 10/325 mg on 02/19/16 (Review 250060).

DOI: 1/5/2012. Patient is a 55-year-old female home attendant who alleges injury to her lower back arising from employment. Per OMNI, she was initially diagnosed with low back pain. Patient is status post left-sided laminectomy with recess decompression at the L5-S1 level on 05/28/15.

DOI: 11/14/2005. Patient is an 83 year old female demonstrator who sustained injury to her lower back while breaking down on her table.

This medication was the only one not prescribed by her normal doctor. She said she took the medication once after surgery but used over the counter medication like Tylenol to treat the pain. She is hesitant to take opioids because of the side effects and possible addiction. She said the medication made her very drowsy.